Food and Formula Reference Guide [FFRG]

Formula Listing

Effective August 1, 2019

Effective August 1, 2019

Page 1 of 11 Missouri Department of Health and Senior Services

WIC and Nutrition Services (07/19)

A. ACRONYMS, ABBREVIATIONS, SYMBOLS, AND CHANGES Updated!

B. MISSOURI WIC APPROVED INFANT FORMULAS AND SPECIAL FORMULAS (EXEMPT INFANT FORMULAS AND WIC-ELIGIBLE NUTRITIONALS) 1. Infants - Contract Formulas Updated! 2. Infants - Exempt Formulas (Special Formulas) Updated! 3. WIC-Eligible Nutritionals (Special Formulas) for Children and Women 4. Guidelines for Issuing Metabolic Formulas 5. Missouri Department of Health and Senior Services - Metabolic Formula Program 6. Food Package Overview for All WIC Categories 7. Maximum Monthly Allowance of Supplemental Foods

A. Acronyms, Abbreviations, Symbols, and Changes

Acronyms and Abbreviations

WIC Cert. = WIC certifier Abbott/Ross = Abbott Nutrition (formerly Ross) fl = fluid

Nutri. = local agency WIC nutritionist MJN = Mead Johnson Nutrition g = grams

CPA = competent professional authority (nutritionist, registered nurse, or registered dietitian) Nestlé = Nestlé Nutrition Ib = pound

RD = registered dietitian at local agency Nutricia = Nutricia North America oz = ounce

State RD = registered dietitian at state agency PBM = PBM Product – Perrigo Nutritionals qt = quart

HCP = health care provider Conc. = concentrated liquid

FBF = fully breastfeeding PWD = powder

WIC-27 = Medical Documentation Form - Health Care Provider Authorization Form RTF = ready-to-feed

CVB = cash value benefit RTU = ready-to-use

Changes 1. Changes to MJN Products: Changes shown below will be implemented in MOWINS Effective October 1, 2019.

Product Status Size Check Description in MOWINS

Enfamil ProSobee

Current (8 fl oz) 6-pack 6-PACK (8 OZ) ENFAMIL PROSOBEE RTU

New 32 fl oz bottle 32 OZ ENFAMIL PROSOBEE RTU

2. Changes to Abbott Products: Changes shown below will be implemented in MOWINS Effective August 1, 2019.

SIMILAC SPECIAL CARE 30 Current 8-PACK (2 OZ) 8-PACK (2 OZ) SIMILAC SPECIAL CARE 30 W/IRON

New 4-PACK (2 OZ) 4-PACK (2 OZ) SIMILAC SPECIAL CARE 30

SIMILAC SPECIAL CARE 24 Current 8-PACK (2 OZ) 8-PACK (2 OZ) SIMILAC SPECIAL CARE 24 W/IRON/LUTEIN/DHA

New 4-PACK (2 OZ) 4-PACK (2 OZ) SIMILAC SPECIAL CARE 24

3. Description change to EleCare for Infants DHA/ARA Effective August 31, 2019

ELECARE FOR INFANTS DHA/ARA Current 14.1 OZ ELECARE FOR INFANTS DHA/ARA (ALL FLAVORS)

New 14.1 OZ ELECARE FOR INFANTS DHA/ARA

Discontinuation Effective August 31, 2019

Enfamil A.R. 6-packs will be discontinued on Saturday, August 31st 2019. The ready-to-use form of Enfamil A.R. will no longer be available.

Effective August 1, 2019

Page 2 of 11 Missouri Department of Health and Senior Services

WIC and Nutrition Services (07/19)

B. Missouri WIC Approved Infant Formulas and Special Formulas (Exempt Infant Formulas and WIC-Eligible Nutritionals)

1. INFANTS – CONTRACT FORMULAS (Enfamil Infant (PWD) is the primary contract infant formula to be issued unless another formula is requested.)

Typ

e

# Contract Formula

Container Size and

Packaging Size

Form Unit in

MOWINS

Yield/Unit in

MOWINS (fl oz)

Manu-facture

r

Nonbreastfeeding Mostly Breastfeeding Some Breastfeeding Children 1

Approval Authority

Age in Months Age in Months Age in Months

0-3 4-5 6-11 0-1 1-3 4-5 6-11 0-1 1-3 4-5 6-11

Co

ntr

act

Fo

rmu

la (

Reb

ate)

1 Enfamil Infant 12.5 oz (6/case)

PWD 1 can 90 MJN 9 10 7 N/A 1 - 4 1 - 5 1 - 4 1 - 9 5 - 9 6 - 10 5 - 7 10 WIC Cert.,

CPA, Nutri., RD

2 Enfamil Gentlease 12.4 oz (6/case)

PWD 1 can 90 MJN 9 10 7 N/A 1 - 4 1 - 5 1 - 4 1 - 9 5 - 9 6 - 10 5 - 7 10 WIC Cert.,

CPA, Nutri., RD

3 Enfamil ProSobee 12.9 oz (6/case)

PWD 1 can 93 MJN 9 10 7 N/A 1 - 4 1 - 5 1 - 4 1 - 9 5 - 9 6 - 10 5 - 7 9 WIC Cert.,

CPA, Nutri., RD

4 Enfamil A.R. 12.9 oz (6/case)

PWD 1 can 91 MJN 9 10 7 N/A 1 - 4 1 - 5 1 - 4 1 - 9 5 - 9 6 - 10 5 - 7 9 WIC Cert.,

CPA, Nutri., RD

5 Enfamil Reguline 12.4 oz (6/case)

PWD 1 can 90 MJN 9 10 7 N/A 1 - 4 1 - 5 1 - 4 1 - 9 5 - 9 6 - 10 5 - 7 10 WIC Cert.,

CPA, Nutri., RD

6 Enfamil Infant 13 fl oz

(12/case) Conc. 1 can 26 MJN 31 34 24 N/A 1 - 14 1 - 17 1 - 12 1 - 31 15 - 31 18 - 34 13 - 24 35

WIC Cert., CPA, Nutri.,

RD

7 Enfamil ProSobee 13 fl oz

(12/case) Conc. 1 can 26 MJN 31 34 24 N/A 1 - 14 1 - 17 1 - 12 1 - 31 15 - 31 18 - 34 13 - 24 35

WIC Cert., CPA, Nutri.,

RD

8 Enfamil Infant 1 qt

(32 fl oz) (6/case)

RTU 1 can 32 MJN 26 28 20 N/A 1 - 12 1 - 14 1 - 10 1 - 26 13 - 26 15 - 28 11 - 20 28 CPA, Nutri.,

RD

9 Enfamil ProSobee New Package

1 qt (32 fl oz) (6/case)

RTU 1 can 32 MJN 26 28 20 N/A 1 - 12 1 - 14 1 - 10 1 - 26 13 - 26 15 - 28 11 - 20 28 CPA, Nutri.,

RD

1Issuing infant formula to children requires medical documentation (WIC-27). Quantity is based on 20 cal./fl oz.

Effective August 1, 2019

Page 3 of 11 Missouri Department of Health and Senior Services

WIC and Nutrition Services (07/19)

2. INFANTS – Exempt Formulas (Special Formulas) Maximum Length of Approval: Last Day of the 6th Month. Updated!

The Food Package III check box on the MOWINS Health Information screen must be checked when issuing any formula in this section.

Typ

e

#

Special Formula Medical

Documentation (WIC-27) Required

Container Size and

Packaging Size

Form Unit in

MOWINS

Yield/Unit in

MOWINS (fl oz)

Manu-facturer

Nonbreastfeeding Mostly Breastfeeding Some Breastfeeding

Children 1

Approval Authority

Age in Months Age in Months Age in Months

0-3 4-5 6-11 0-1 1-3 4-5 6-11 0-1 1-3 4-5 6-11

Pre

mat

ure

Fo

rmu

la a

nd

Fo

rmu

la in

Nu

rset

te

10 EnfaCare NeuroPro 12.8 oz (6/case)

PWD 1 can 82 MJN 10 11 8 N/A 1 - 5 1 - 6 1 - 4 1 - 10 6 - 10 7 - 11 5 - 8 11 CPA,

Nutri., RD

11 EnfaCare NeuroPro Effective 10-01-19

1 qt (32 fl oz) (6/case

RTU 1 bottle 32 MJN 26 28 20 N/A 1 - 12 1 - 14 1 - 10 1 - 26 13 - 26 15 - 28 11 - 20 28 CPA,

Nutri., RD

EnfaCare Ending 09-30-19

8 fl oz (4 x 6-packs)

RTU 6-pack 48 MJN 17 19 13 N/A 1 - 8 1 - 9 1 - 7 1 - 17 9 - 17 10 - 19 8 - 13 18 CPA,

Nutri., RD

12 Similac NeoSure 13.1 oz (6/case)

PWD 1 can 87 Abbott/Ross

10 11 8 N/A 1 - 5 1 - 6 1 - 4 1 - 10 6 - 10 7 - 11 5 - 8 10 CPA,

Nutri., RD

13 Similac NeoSure 1 qt

(32 fl oz) (6/case)

RTU 1 bottle 32 Abbott/Ross

26 28 20 N/A 1 - 12 1 - 14 1 - 10 1 - 26 13 - 26 15 - 28 11 - 20 28 CPA,

Nutri., RD

14 Enfamil Premature with Iron (20 cal.)

2 fl oz (8 x 6-packs)

RTU 6-pack 12 MJN 69 74 53 N/A 1 - 32 1 - 37 1 - 26 1 - 69 33 - 69 38 - 74 27 - 53 0 Nutri., RD

15 Enfamil Premature with Iron (24 cal.)

2 fl oz (8 x 6-packs)

RTU 6-pack 12 MJN 69 74 53 N/A 1 - 32 1 - 37 1 - 26 1 - 69 33 - 69 38 - 74 27 - 53 0 Nutri., RD

16 Enfamil Premature with Iron (30 cal.)

2 fl oz (8 x 6-packs)

RTU 6-pack 12 MJN 69 74 53 N/A 1 - 32 1 - 37 1 - 26 1 - 69 33 - 69 38 - 74 27 - 53 0 Nutri., RD

17 Pregestimil (20 cal.) 2 fl oz

(8 x 6-packs) RTU 6-pack 12 MJN 69 74 53 N/A 1 - 32 1 - 37 1 - 26 1 - 69 33 - 69 38 - 74 27 - 53 0

CPA, Nutri., RD

18 Pregestimil (24 cal.) 2 fl oz

(8 x 6-packs) RTU 6-pack 12 MJN 69 74 53 N/A 1 - 32 1 - 37 1 - 26 1 - 69 33 - 69 38 - 74 27 - 53 0

CPA, Nutri., RD

19 Similac Special Care with Iron (20 cal.)

2 fl oz (6 x 8-packs)

RTF 8-pack 16 Abbott/ Ross

52 56 40 N/A 1 - 24 1 - 28 1 - 20 1 - 52 25 - 52 29 - 56 21 - 40 0 Nutri., RD

20 Similac Special Care with Iron (24 cal.) New Package

2 fl oz (12 x 4-packs)

RTF 4-pack 8 Abbott/ Ross

104 114 80 N/A 1 - 48 1 - 59 1 - 42 1 - 104 49 - 104 60 - 114 43 - 80 0 Nutri., RD

21 Similac Special Care with Iron (30 cal.) New Package

2 fl oz (12 x 4-packs)

RTF 4-pack 8 Abbott/ Ross

104 114 80 N/A 1 - 48 1 - 59 1 - 42 1 - 104 48 - 104 60 - 114 43 - 80 0 Nutri., RD

22 EleCare For Infants DHA/ARA

14.1 oz (6/case)

PWD 1 can 95 Abbott/ Ross

9 10 7 N/A 1 - 4 1 - 5 1 - 4 1 - 9 5 - 9 6 - 10 5 - 7 9 CPA,

Nutri., RD

Effective August 1, 2019

Page 4 of 11 Missouri Department of Health and Senior Services

WIC and Nutrition Services (07/19)

Typ

e

#

Special Formula Medical

Documentation (WIC-27) Required

Container Size and

Packaging Size

Form Unit in

MOWINS

Yield/Unit in

MOWINS (fl oz)

Manu-facturer

Nonbreastfeeding Mostly Breastfeeding Some Breastfeeding

Children 1

Approval Authority

Age in Months Age in Months Age in Months

0-3 4-5 6-11 0-1 1-3 4-5 6-11 0-1 1-3 4-5 6-11

23 Neocate Infant Formula DHA/ARA

14.1 oz (4/case)

PWD 1 can 97 Nutricia 8 9 7 N/A 1 - 4 1 - 5 1 - 3 1 - 8 5 - 8 6 - 9 4 - 7 9 CPA,

Nutrí., RD

H

ypo

alle

rgen

ic F

orm

ula

24 Nutramigen 13 fl oz

(12/case) Conc. 1 can 26 MJN 31 34 24 N/A 1 - 14 1 - 17 1 - 12 1 - 31 15 - 31 18 - 34 13 - 24 35 CPA,

Nutri., RD

25 Nutramigen 1 qt

(32 fl oz) (6/case)

RTU 1

bottle 32 MJN 26 28 20 N/A 1 - 12 1 - 14 1 - 10 1 - 26 13 - 26 15 - 28 11 - 20 28 CPA,

Nutri., RD

26 Nutramigen with Enflora LGG

12.6 oz (6/case)

PWD 1 can 87 MJN 10 11 8 N/A 1 - 5 1 - 6 1 - 4 1 - 10 6 - 10 7 - 11 5 - 8 10 CPA,

Nutri., RD

27 Pregestimil 16 oz

(6/case) PWD 1 can 112 MJN 7 8 6 N/A 1 - 3 1 - 4 1 - 3 1 - 7 4 - 7 5 - 8 4 - 6 8

CPA, Nutri., RD

28 PurAmino 14.1 oz (4/case)

PWD 1 can 98 MJN 8 9 7 N/A 1 - 4 1 - 5 1 - 3 1 - 8 5 - 8 6 - 9 4 - 7 9 CPA, Nutri., RD

29 Similac Alimentum 12.1 oz (6/case)

PWD 1 can 87 Abbott/ Ross

10 11 8 N/A 1 - 5 1 - 6 1 - 4 1 - 10 6 - 10 7 - 11 5 - 8 10 CPA,

Nutri., RD

30 Similac Alimentum 1 qt

(32 fl oz) (6/case)

RTU 1 can 32 Abbott/ Ross

26 28 20 N/A 1 - 12 1 - 14 1 - 10 1 - 26 13 - 26 15 - 28 11 - 20 28 CPA,

Nutri., RD

31 3232A 16 oz PWD 1 can varies MJN varies2 N/A varies2 varies2 State RD

32 Calcilo XD 13.2 oz (6/case)

PWD 1 can 96 Abbott/ Ross

9 10 7 N/A 1 - 4 1 - 5 1 - 4 1 - 9 5 - 9 6 - 10 5 - 7 9 RD, Nutri.

33 Enfaport 6 fl oz

(4 x 6-pack) RTU 6-pack 36 MJN 23 25 17 N/A 1 - 10 1 - 13 1 - 9 1 - 23 11 - 23 14 - 25 10 - 17 25 RD, Nutri.

34 RCF-Ross Carbohydrate Free

13 fl oz (12/case)

Conc. 1 can 26 Abbott/ Ross

31 34 24 N/A 1 - 14 1 - 17 1 - 12 1 - 31 15 - 31 18 - 34 13 - 24 35 RD, State

RD

35 Similac PM 60/40 14.1 oz (6/case)

PWD 1 can 102 Abbott/ Ross

8 9 6 N/A 1 - 4 1 - 5 1 - 3 1 - 8 5 - 8 6 - 9 4 - 6 8 RD, Nutri.

1. Issuing infant formula to children requires medical documentation (WIC-27). Maximum quantity allowance is based on the yield per can for infant standard dilution. 2. Reconstituted yield per can varies and is dependent on age, body weight, and medical condition of the participant. Contact State RD for a maxium monthly allowance.

Effective August 1, 2019

Page 5 of 11 Missouri Department of Health and Senior Services

WIC and Nutrition Services (07/19)

3. WIC– eligible Nutritionals (Special Formulas) for Children and Women - Maximum Length of Approval: Last Day of the 6th Month. The Food Package III check box on the MOWINS Health Information screen must be checked when issuing any formula in this section.

Descriptions in MOWINS for formula available in one or more flavors will be listed as “all flavors.”

# Special Formula for Children and Women

Medical Documentation (WIC-27) Required Container Size and

Packaging Size Form

Unit in MOWINS

Yield/Unit in MOWINS (fl oz)

Manufacturer Children Women Approval Authority

36 3232A 16 oz PWD 1 can varies MJN Varies1 0 State RD

37 Boost (chocolate, strawberry, vanilla) 8 fl oz (4 x 6-pack) RTU 6-pack 48 Nestlé 0 18 x 6-pack CPA, Nutri., RD

38 Boost Kid Essentials (chocolate, vanilla) 8.25 fl oz (4 x 4-packs) RTU 4-pack 33 Nestlé 27 x 4-pack 0 CPA, Nutri., RD

39 Boost Kid Essentials 1.5 cal. (chocolate, strawberry, vanilla) 8 fl oz (27/case) RTU 1 can 8 Nestlé 113 0 Nutri., RD

40 Boost Kid Essentials with Fiber 1.5 cal. (vanilla) 8 fl oz (27/case) RTU 1 can 8 Nestlé 113 0 Nutri., RD

41 Bright Beginnings Soy Pediatric Drink (vanilla) 8 fl oz (4 x 6-packs) RTU 6-pack 48 PBM

[Nestlé] 18 x 6-pack 0 CPA, Nutri., RD

42 Compleat Pediatric 8.45 fl oz (24/case) RTU 1 can 8.45 Nestlé 107 0 Nutri., RD

43 Compleat Pediatric Reduced Calorie 8.45 fl oz (24/case) RTU 1 can 8.45 Nestlé 107 0 Nutri., RD

44 EleCare Jr. (banana, chocolate, unflavored, vanilla) 14.1 oz (6/case) PWD 1 can 62 Abbott/Ross 14 0 CPA, Nutri., RD

45 Ensure (all flavors) 8 fl oz (4 x 6-pack) RTU 6-pack 48 Abbott/Ross 0 18 x 6-pack CPA, Nutri., RD

46 Glucerna Shake (butter pecan, chocolate, strawberry, vanilla) 8 fl oz (4 x 6-pack) RTU 6-pack 48 Abbott/Ross 18 x 6-pack 18 x 6-pack RD, State RD

47 Isosource 1.5 with Fiber 8.45 fl oz (24/case) RTU 1 can 8.45 Nestlé 107 107 RD, State RD

48 KetoCal (3:1) 11 oz (6/case) PWD 1 can 71 Nutricia 12 0 RD, State RD

49 KetoCal (4:1) 11 oz (6/case) PWD 1 can 51 Nutricia 17 0 RD, State RD

50 Monogen (Monthly quantity is based on 30 cal./fl oz) 400 g (14.1 oz)

(6/case) PWD 1 can 58 Nutricia 15 15 State RD

51 Neocate Junior with Prebiotics (strawberry, unflavored, vanilla) 400 g (14.1 oz)

(4/case) PWD 1 can 65 Nutricia 14 0 RD, State RD

52 Neocate Splash (grape, orange-pineapple, tropical fruit, unflavored) 8 fl oz (27/case) RTU 1 can 8 Nutricia 113 0 RD, State RD

53 Nutren Jr. (vanilla) 8.45 fl oz (24/case) RTU 1 can 8.45 Nestlé 107 0 Nutri., RD

54 Nutren Jr. with Fiber (vanilla) 8.45 fl oz (24/case) RTU 1 can 8.45 Nestlé 107 0 Nutri., RD

55 PediaSure (all flavors) 8 fl oz (4 x 6-pack) RTU 6-pack 48 Abbott/Ross 18 x 6-pack 0 CPA, Nutri., RD

56 PediaSure with Fiber (strawberry, vanilla) 8 fl oz (4 x 6-pack) RTU 6-pack 48 Abbott/Ross 18 x 6-pack 0 CPA, Nutri., RD

57 PediaSure 1.5 (vanilla) 8 fl oz (24/case) RTU 1 can 8 Abbott/Ross 113 0 Nutri., RD

58 PediaSure 1.5 with Fiber (vanilla) 8 fl oz (24/case) RTU 1 can 8 Abbott/Ross 113 0 Nutri., RD

59 PediaSure Enteral Formula 1.0 cal. 8 fl oz (24/case) RTU 1 can 8 Abbott/Ross 113 0 Nutri., RD

Effective August 1, 2019

Page 6 of 11 Missouri Department of Health and Senior Services

WIC and Nutrition Services (07/19)

# Special Formula for Children and Women

Medical Documentation (WIC-27) Required Container Size and

Packaging Size Form

Unit in MOWINS

Yield/Unit in MOWINS (fl oz)

Manufacturer Children Women Approval Authority

60 PediaSure Enteral Formula 1.0 cal. with Fiber 8 fl oz (24/case) RTU 1 can 8 Abbott/Ross 113 0 Nutri., RD

61 PediaSure Peptide 1.0 cal. (strawberry, unflavored, vanilla) 8 fl oz (24/case) RTU 1 can 8 Abbott/Ross 113 0 RD, State RD

62 PediaSure Peptide 1.5 cal. (vanilla) 8 fl oz (24/case) RTU 1 can 8 Abbott/Ross 113 0 RD, State RD

63 PediaSure SideKicks (chocolate, strawberry, vanilla) 8 fl oz (4 x 6-pack) RTU 1 can 48 Abbott/Ross 18 x 6-pack 0 RD, State RD

64 Pepdite Jr. 1.8 oz (15/case) PWD 1 can 8 Nutricia 113 0 CPA, Nutri., RD

65 Peptamen Jr. 1.5 8.45 fl oz (24/case) RTU 1 can 8.45 Nestlé 107 0 CPA, Nutri., RD

66 Peptamen Jr. with Fiber (vanilla) 8.45 fl oz (24/case) RTU 1 can 8.45 Nestlé 107 0 CPA, Nutri., RD

67 Peptamen Jr. with Prebio (chocolate, vanilla) 8.45 fl oz (24/case) RTU 1 can 8.45 Nestlé 107 0 CPA, Nutri., RD

68 Portagen 14.46 oz (6/case) PWD 1 can 64 MJN 14 14 RD, State RD

69 Super Soluble Duocal 14.1 oz (6/case) PWD 1 can varies1 (91) Nutricia 10 10 State RD

70 Suplena with Carb Steady (vanilla) 8 fl oz (24/case) RTU 1 can 8 Abbott/Ross 113 113 RD, State RD

71 Tolerex 2.82 oz (60/case) PWD 1 can 10 Nestlé 0 91 packets RD, State RD

72 Vivonex T.E.N. 2.84 oz (60/case) PWD 1 can 10 Nestlé 0 91 packets RD, State RD

1. Reconstituted yield per can varies and is dependent on age, body weight, and medical condition of the participant. Contact State RD for a maxium monthly allowance.

Effective August 1, 2019

Page 7 of 11 Missouri Department of Health and Senior Services

WIC and Nutrition Services (07/19)

4. Guidelines for Issuing Metabolic Formulas The Food Package III check box on the MOWINS Health Information screen must be checked when issuing any formula in this section.

# Metabolic Formula Size Packaging

Size Form Manufacturer

Unit in MOWINS

Yield in MOWINS (fl oz)

Eligible Category Guidelines

Infants Children Women

73 BCAD 1 16 oz 6/case PWD MJN 1 can varies varies varies 0 Medical Documentation: Medical documentation (WIC-27)

is required to issue metabolic formula.

Approval Length: Two (2) months

Approval Authority: State RD

Monthly Allowance: The local agency should obtain instructions for the correct amount of water and powder from the participant's physician. Product yield per can (fl oz) for one (1) can varies. The monthly allowance for the participant can be determined based on instructions from the physician and cannot exceed the amount allowed by the WIC program if WIC is a primary payer.

Payer of Metabolic Formulas and Documentation:

1. If the participant does not have private medical insurance, the DHSS Metabolic Formula Program (DHSS MFP) is the primary payer. (See page 8.)

2. Notify the participant or the parent/guardian that the DHSS MFP is the primary payer for the prescribed formula and give referral.

3. Inform the participant or the parent/guardian that WIC will only issue the metabolic formula for two (2) months and issue WIC checks for other food in the food package as prescribed.

4. While waiting for approval from the DHSS MFP, the CPA shall proceed with the issuance of metabolic formula using the WIC Food Package III for up to two (2) months.

5. Scan the completed medical documentation (WIC-27) into MOWINS and document the payment source in the SOAP notes.

6. Follow-up must be done and documented in the SOAP notes to ensure the nutritional needs of the participant are being met.

Maximum Monthly Allowance: The appropriate concentration of metabolic formula may vary between individuals and over time. The volume yield per can must be determined based on the mixing instructions and prescription from the physician. No single mixing ratio would suffice for the variety of genetic variations and patient conditions.

74 GA 16 oz 6/case PWD MJN 1 can varies varies varies varies

75 HCY 1 16 oz 6/case PWD MJN 1 can varies varies varies 0

76 HCY 2 16 oz 6/case PWD MJN 1 can varies 0 varies varies

77 I-Valex-1 14.1 oz 6/case PWD Abbott/Ross 1 can varies varies varies 0

78 Ketonex 1 14.1 oz 6/case PWD Abbott/Ross 1 can varies 0 varies varies

79 Ketonex 2 14.1 oz 6/case PWD Abbott/Ross 1 can varies 0 varies varies

80 LMD 454 g (1 lb) 6/case PWD MJN 1 can varies varies varies varies

81 MSUD ANAMIX Early Years

400 g (14.1 oz) 6/case PWD Nutricia 1 can varies varies varies 0

82 MSUD Maxamum 454 g (1 lb) 6/case PWD Nutricia 1 can varies 0 0 varies

83 OA 1 16 oz 6/case PWD MJN 1 can varies varies varies 0

84 OA 2 16 oz 6/case PWD MJN 1 can varies 0 varies varies

85 PKU Periflex Early Years 400 g (14.1 oz) 6/case PWD Nutricia 1 can varies varies varies 0

86 PFD Toddler 454 g (1 lb) 6/case PWD MJN 1 can varies varies varies 0

87 Phenex-1 14.1 oz 6/case PWD Abbott/Ross 1 can varies varies varies 0

88 Phenex-2 14.1 oz 6/case PWD Abbott/Ross 1 can varies 0 varies varies

89 Phenyl-Free 1 16 oz 6/case PWD MJN 1 can varies varies varies 0

90 TYROS 1 16 oz 6/case PWD MJN 1 can varies varies varies 0

91 WND 1 16 oz 6/case PWD MJN 1 can varies varies varies 0

92 WND 2 16 oz 6/case PWD MJN 1 can varies 0 varies varies

93 XPhe Maxamum 16 oz 6/case PWD Nutricia 1 can varies 0 0 varies

Effective August 1, 2019

Page 8 of 11 Missouri Department of Health and Senior Services

WIC and Nutrition Services (07/19)

5. Missouri Department of Health and Senior Services - Metabolic Formula Program

Website: http://health.mo.gov/living/families/genetics/metabolicformula/index.php/

Telephone: 573-751-6266 or 800-877-6246 or 314-877-0225

Confidential Fax: 573-751-6185

Email: Nancy.Althouse-Hill@health.mo.gov

Medical Eligibility: Medical eligibility for the DHSS Metabolic Formula Program must be documented and include a written medical diagnosis for one of

the conditions listed below:

1. Phenylketonuria (PKU)

2. Maple Syrup Urine Disease (MSUD)

3. Glutaric Acidemia

4. Homocystinuria

5. Methylmalonic Acidemia

6. Citrullinemia

7. Argininosuccinic Acidemia

8. Isovaleric Acidemia

9. 3-Hydroxy-3-Methylglutaryl CoA lyase Deficiency (HMG)

10. 3-Methylcrotonyl CoA Carboxylase Deficiency (3MCC)

11. Propionic Acidemia

12. Long-chain 3-Hydroxyacyl CoA Dehydrogenase Deficiency (LCHAD)

13. Very-long-chain Acyl-CoA Dehydrogenase Deficiency (VLCAD)

14. Ornithine Transcarbamylase Deficiency (OTC)

15. Tyrosinemia (Type I, II, and III)

Effective August 1, 2019

Page 9 of 11 Missouri Department of Health and Senior Services

WIC and Nutrition Services (07/19)

6. Food Package Overview for All WIC Categories

Food Package Category Eligibility

Food Package I and II

Infants

This food package is designed for issuance to infant participants from birth through 11 months of age:

• Fully breastfeeding: The infant does not receive formula from WIC.

• Mostly breastfeeding: This infant is mostly breastfed, but also receives infant formula up to the maximum quantity allowed for partially breastfed

infants. This food package is not available for infants 0-1 month.

• Some breastfeeding: The infant is some breastfed and receives formula in excess of the quantity allowed for partially breastfed infants.

• Nonbreastfeeding: The infant is fully formula fed.

Food Package III

Participants with

qualifying conditions

This food package is reserved for issuance to women, infants, and children participants who have a documented qualifying condition that requires

the use of a WIC formula (infant formula, exempt infant formula, or WIC-eligible nutritional). Medical documentation (WIC-27) is required.

Food Package IV

Children

12-59 months This food package is designed for issuance to participants 12 to 59 months of age.

Food Package V

Pregnant

Mostly Breastfeeding

Women

This food package is designed for issuance to:

• Women participants with singleton pregnancies.

• Women, up to one (1) year, whose infant is mostly breastfed. (Mostly Breastfeeding)

Food Package VI

Nonbreastfeeding

Women

Some Breastfeeding

Women

This food package is designed for issuance to:

• Women up to six (6) months postpartum whose infants are fully formula fed. (Nonbreastfeeding)

• Women up to six (6) months postpartum whose infants receive formula in excess of the quantity allowed for mostly breastfed infants. (Some

Breastfeeding)

Food Package VII

Fully Breastfeeding

Women

Women qualified for

Food Package III

This food package is designed for issuance to:

• Breastfeeding women up to one (1) year postpartum whose infants do not receive infant formula from WIC. (Fully

Breastfeeding)

• Mostly breastfeeding women with multiple infants from the same pregnancy.

• Pregnant women who are fully or mostly breastfeeding.

• Pregnant women with two (2) or more fetuses.

[Note] Women participants fully breastfeeding multiple infants from the same pregnancy receive one and a half (1.5) times the supplemental food provided in Food Package VII.

Mostly and Some Breastfeeding Women with Twins Mother’s Food Package

Twins: Some breastfeeding under six (6) months of age. The mother would receive Food Package VI.

Twins: Some breastfeeding older than six (6) months of age. If the infants are over six (6) months of age, the mother would not receive a food package.

Twins: One (1) infant (some breastfeeding) and the other infant (mostly breastfeeding).

The mother would receive Food Package V because one (1) of her infants qualifies to receive the mostly breastfeeding package.

[Note] Food Package VII does not apply to a mother tandem-breastfeeding multiples (Example: An infant two (2) months of age and an infant 11 months of age).

Effective August 1, 2019

Page 10 of 11 Missouri Department of Health and Senior Services

WIC and Nutrition Services (07/19)

7. Maximum Monthly Allowance of Supplemental Foods

Food Items

Infant 6-8

Months Infant 9-11 Months Children (1-4)

Pregnant Mostly

breastfeeding

Nonbreastfeeding Some

breastfeeding

Fully breastfeeding Mostly breastfeeding multiples Pregnant with multiples Pregnant and fully or mostly

breastfeeding

Food Package II and III

Food Package II and III Food Package IV Food Package V Food Package VI Food Package VII

WIC formula Pages 2-4 and 71 Pages 2-4 and 71 Pages 5-7 1 Pages 5-7 1 Pages 5–7 1 Pages 5–7 1

Infant cereal 24 oz 24 oz 32 oz2 32 oz2 32 oz2 32 oz2

Infant food (fruit and vegetables)

64 - 4 oz (FBF)

32 - 4 oz3

Infant Food Only 64 - 4 oz (FBF)

32 - 4 oz3

36 - 4 oz for $94 40 - 4 oz for $114 40 - 4 oz for $114 40 - 4 oz for $114

Fresh fruit and vegetables (CVB)

Not allowed

Infant Food and CVB

32 - 4 oz and $8 (FBF) 5

16 - 4 oz and $43,5

$9 $11 $11 $11

Infant meats (FBF only) 31 x 2.5 oz 31 x 2.5 oz Not allowed Not allowed Not allowed Not allowed

Juice, single strength Not allowed Not allowed 128 fl oz

2 x 64 oz container 144 fl oz

3 x 11.5/12 oz frozen 96 fl oz

2 x 11.5/12 oz frozen 144 fl oz

3 x 11.5/12 oz frozen

Milk, fluid6 Not allowed Not allowed 16 qt6 22 qt6 16 qt6 24 qt6

Cheese6 Not allowed Not allowed 06 06 06 1 lb6

Breakfast cereal Not allowed Not allowed 36 oz 36 oz 36 oz 36 oz

Eggs Not allowed Not allowed 1 dozen 1 dozen 1 dozen 2 dozen

Whole grains Not allowed Not allowed 2 lb 1 lb 0 1 lb

Fish (canned) Not allowed Not allowed 0 0 0 30 oz

Legumes, dry/canned AND peanut butter

Not allowed Not allowed

1 x [16-18 oz peanut butter OR 1 lb dry OR 4-16 oz can beans]

2 x [16-18 oz peanut butter OR 1 lb dry OR 4-16 oz can beans]

1 x [16-18 oz peanut butter OR 1 lb dry OR 4-16 oz can beans]

2 x [16-18 oz peanut butter OR 1 lb dry OR 4-16 oz can beans]

Effective August 1, 2019

Page 11 of 11 Missouri Department of Health and Senior Services

WIC and Nutrition Services (07/19)

[Note- see page 11]

Food Package III is for women, infants, and children who have a documented qualifying condition that requires the use of a WIC formula (infant formula, exempt infant formula, or WIC-eligible nutritional) because the use of conventional food is precluded, restricted, or inadequate to address their special nutritional needs.

1. Food and Formula Reference Guide (FFRG) Formula Listing.

2. 32 ounces of infant cereal may be substituted for 36 ounces of adult cereal if the participant also receives a formula/WIC-eligible nutritional from the Missouri WIC program under Food Package III. Completion of the medical documentation (WIC-27) is required.

3. Food items and quantities for mostly breastfeeding, some breastfeeding, and nonbreastfeeding infants.

4. Infant food may be issued to children and women with qualifying conditions instead of the CVB. (Food Package III)

Children – 144 ounces (36 – 4 oz) of infant food fruit/vegetables may be substituted for the $9 CVB.

Women – 160 ounces (40 – 4 oz) of infant food fruit/vegetables may be substituted for the $11 CVB.

5. CVB for fresh fruit and vegetables may be substituted for infant food fruit and vegetables for infants nine (9) to 11 months of age. (Food Package II and III)

CVB for fresh fruit and vegetables can be substituted for a proportion of infant food fruit and vegetables in Food Packages II and III based upon an individual assessment conducted by a CPA.

Fully breastfed infants have the option to receive an $8 CVB for fresh fruit and vegetables and up to 128 ounces (32 – 4 oz) infant food fruit and vegetables.

Partially breastfed and fully formula fed infants have the option to receive a $4 CVB for fresh fruit and vegetables and up to 64 ounces (16 – 4 oz) of infant food fruit and vegetables.

6. Standard food packages for children and women allow cheese to be issued as a milk substitute (two (2) pounds for fully breastfeeding women and one (1) pound for all other categories).

Refer to the FFRG – Guidelines for more information.